=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851455653
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORGE MANUEL MACHICOTE D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 03/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 CALLE BETANCES
-----------------------------------------------------
City | CIALES
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00638-3249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-871-2850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 CALLE BETANCES
-----------------------------------------------------
City | CIALES
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00638-3249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2696
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------